We are so excited that you found iCare. We look forward to meeting you soon at one of our events. Please fill out this form to officially register as a participant in our system. Once we receive your registration, you will be part of our participant distribution list. You will be notified periodically by email about upcoming events.

Participant Registration Form

General Information about you

Name
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First Name Last Name

What do you like to be called? (Nickname)

Address
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Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Mobile Phone Number
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Area Code Phone Number

Do you have an e-mail address?
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Yes No

Our primary form of contact is email. Please list the best email address for notifications from iCare of Northeast Kansas.

Birth Date (this will be used for birthday celebrations)

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Month
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Day Year

Gender

Male Female

Emergency Contact Name
*

First Name Last Name

Relationship to Participant?

Emergency Contact Phone Number
*

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Area Code Phone Number

Home Parish

Enroll in Religious Ed/Sacramental Prep

Religious begins at Queen of the Holy Rosary in Overland Park, KS on 9/9/17.

The enrollment deadline is 6/30/17 (Not available in Topeka yet). If you would like to enroll, please complete this section, if not simply scroll down to the section "Other Information" and complete the form.

I would like to enroll in Religious Education
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Yes No (Please proceed to the "Other Information" section)

Parent/Guardian Name

First Name Last Name

Parent/Guardian Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Country

Parent/Guardian email

Which Sacraments have you received?

Baptism Reconciliation First Communion Confirmation I have not received any sacraments I have received all my sacraments, but I am interested in ongoing formation.

In order to plan for effective catechesis, we need to know more about you. Please complete the following information:

Tell us about your specific disability.

I am...

Verbal Non-Verbal

If Non-Verbal, tell us about the communication system you use

I am...

A Reader A Non-Reader

If you can read, what is your reading level?

Tell us about any physical limitations you may have.

What is your preferred level of support?

One-on-one Small Group setting (3-5 participants) Large Group setting (6-10 participants)

PHOTO and MEDIA WAIVER - I hereby consent to my child/ward/self being interviewed, photographed and/or videotaped by representatives or volunteers of iCare of Northeast, Kansas or the Archdiocese of Kansas City in Kansas. Any information or images obtained from those activities may be reproduced by iCare of Northeast, Kansas and/or the public media for use in advertising, publicity, social media or educational activities. I hereby waive any claims I may have and release iCare of Northeast, Kansas and its representatives and volunteers from any liability or claims arising out of such activities.
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